Screening at Points of Entry: Pros & Cons. Dr. Jarnail Singh CAPSCA Technical Advisor / CAAS

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1 Screening at Points of Entry: Pros & Cons Dr. Jarnail Singh CAPSCA Technical Advisor / CAAS 1

2 Keep everything and everybody in 2 Keep everything and everybody in CONTAINMENT Public Health Event: Affected area Keep everything and everybody in Keep everything and everybody in

3 Possible? Implementable? Legal? Outcome? Ethical? 3

4 International Health Regulations (2005) A global legal framework for public health security IHR (2005) came into force on 15 June 2007* Legally binding for the world s countries that have agreed to follow the same rules to secure international health. Courtesy WHO

5 Purpose of the IHR (2005) To prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade Article 2 Courtesy WHO

6 96 Articles Article 14, International Convention on Civil Aviation

7 Basis for Action - health Article 14, International Convention on Civil Aviation: Each contracting State agrees to take effective measures to prevent the spread by means of air navigation of cholera, typhus (epidemic), smallpox, yellow fever, plague, and such other communicable diseases as the contracting States shall from time to time decide to designate.

8 Basis for Action - health Article 14, International Convention on Civil Aviation:.and to that end contracting States will keep in close consultation with the agencies concerned with international regulations relating to sanitary measures applicable to aircraft.

9 19 ICAO Annexes contain SARPs (Standards and Recommended Practices) Annex 1 Personnel Licensing Annex 2 Rules of the Air Annex 3 Meteorological Service for International Air Navigation Annex 4 Aeronautical Charts Annex 5 Units of Measurement to be Used in Air and Ground Operations Annex 6 Operation of Aircraft * Annex 7 Aircraft Nationality and Registration Marks Annex 8 Airworthiness of Aircraft Annex 9 Facilitation * Annex 10 Aeronautical Telecommunications Annex 11 Air Traffic Services Procedures for Air Navigation Services Air Traffic Management (PANS-ATM) * Annex 12 Search and Rescue Annex 13 Aircraft Accident and Incident Investigation Annex 14 Aerodromes * Annex 15 Aeronautical Information Services Annex 16 Environmental Protection Annex 17 Security: Safeguarding International Civil Aviation Against Acts of Unlawful Interference Annex 18 The Safe Transport of Dangerous Goods by Air Annex 19 Safety Management System

10 Distilled into.. State Guidelines : ICAO Airline Guidelines : IATA Airport Guidelines : ACI

11 Annex 6 Annex 9 Annex 11 Annex 14 PANS ATM Annex 18 IHR implementation

12 Changes to SARPs 2009 Annex 6 Operation of Aircraft On board medical supplies Inclusion of a universal precaution kit Managing on board communicable disease event

13 Changes to SARPs 2007 Annex 9 - Facilitation States must have a pandemic preparedness plan for aviation

14 Changes to SARPs 2009 Annex 11 Air Traffic Services and PANS-ATM Detailed procedure for utilising ATC for notifying destination of on board public health event Public health emergencies included in contingency planning

15 Changes to SARPs 2009 Annex 14 Aerodromes Public health emergencies included in aerodrome emergency plan

16 Departing Passengers (a) Point of ticket enquiry / trip planning Web based Phone booking Travel agents Airline? Responsibility Advisory Message Not To Travel if ill

17 *Educate and Prepare the public: Do Not Travel If You Have A Communicable Disease *Prime the Travel Industry Sample Message: Passengers are advised not to travel if they are ill or suspect that they may have a communicable disease. You may not be allowed to board the flight if it is suspected that you have a communicable disease. If in doubt contact your doctor for advise.

18 Should I take the flight?

19 Sample Message: Screening for MERS CoV is in place at XXX airport. Passengers with symptoms of flu will not be allowed to enter the airport and will not be checked in or allowed to board any flight. If in doubt please contact your doctor before proceeding with your travel plans. **If you have been in (name of place with outbreak) in the last (?week) please seek your doctor s advise before making any travel plans.

20 (b) Travel plans made / Ticket Purchased Arrival at airport: i) Before entry to airport:?feasible??responsibility? ii) Appropriate Advisory Signs/Display boards/messages? Screening prior to entry to airport (if outbreak has occurred in State) --? Questionnaire for symptoms and if coming from outbreak area. Positive No Entry. Refer to secondary screening Negative Proceed to Check-in PPE for staff & suspect passengers

21 ii) At Check-in: Appropriate Advisory Signs/Display boards/ Voice Messages over airport Public Address system If Screening has not been done:? Screening prior to entry to airside (if outbreak has occurred in State)? Questionnaire: for symptoms and if coming from outbreak area. Appropriate PPE for Check-in staff and suspect passengers

22 In Flight Screening? Role of cabin crew Procedure for handling an ill passenger Role of the Pilot in Command 22

23 23 Screening at Arrival

24 24 How and where do you do the screening In the aircraft After disembarkation Who does the screening What do you screen for Contact tracing What to do with the contacts

25 If you pick up a positive during screening what next? Secondary screening where? Hospital? Isolation Quarantine? 25

26 What is the role of temperature screening in relation to the clinical features of disease? Incubation period of X days Infectious XX days before onset of symptoms Situation may change as more epidemiological data is accumulated. Key Role For WHO & CDC to screen or not to screen

27 Arriving Aircraft With Suspect Case/s On Board Measures for suspect case/s Measures for other passengers Measures for Crew Disinfection of aircraft Baggage Ramp workers Others Segregation from suspect case Advisory information Possible Quarantine National Health Authority Secondary Screening Designated Ambulance/s Designated Hospital/s

28 Airport Workers & Airline Workers Protection of airport workers Preventive strategies for airport workers What happens when airport worker/s fall ill with prevailing PHE Contingency plans Education & Basic Hygiene Measures Front Line staff -- for priority in vaccination programs Screening measures prior to reporting for work

29 ? To Screen? Or Not To Screen

30 Options for Interventions at International Points of Entry Reference: Suggested framework for assessment and decision making Responding to Pandemic H1N1 2009: Options for interventions at International Points of Entry : WHO Regional Office for the Western Pacific interim option paper, 20 May 2009

31 Public Health Measures Available (Theoretically) - at an international border - 1. Travel and screening (prevention, detection) Health advice and alerts to travellers Health declaration form Temperature screening On-board identification of suspected travellers International travel advisory, restriction, border closure? 2. Management of symptomatic & exposed travellers Symptomatic travellers (isolation & treatment ) Exposed travellers (quarantine? )

32 Public health measures in response to pandemic influenza Options for public health intervention at international points of entry (POE)

33 Options: Key considerations International border health measures should be implemented under the framework of the new International Health Regulations Decision on public health measures based on assessed risks Public health measures should be evidence-based whenever possible Countries should balance the benefits against the costs and potential consequences Desirability of harmonization of interventions at international POE Planning, coordination and communication is essential

34 Comparative risk of outbreaks Transmissibility Severity of Disease (Morbidity & Mortality) High Low H5N1 SARS High 1918 Pandemic Low Pandemic (H1N1) 2009 Seasonal Flu

35 Possible strategies based on risk category Transmissibility Low High Severity of Disease (Morbidity & Mortality) High Aiming at preventing disease importation and containing the virus Aiming at rapid containment at the early stage, and mitigating the impacts, if containment not possible Low Routine public health measures without additional aggressive interventions Aiming at reducing transmission and mitigating impact with focus on vulnerable population

36 Matching cost and consequences of interventions with risk level (example) More acceptable interventions 1918 pandemic virus or worse SARS A C D Level of Risk New H1N1??? Seasonal Influenza F B Less acceptable interventions E E.g. Health alert or advice E.g. Temperature screei E.g. Border closure Cost s and Consequences

37 The presentation concerning traveller screening on Biodiaspora suggested that: Exit screening at airports with greatest traffic levels is most effective, least disruptive but places further burden on the source country Entry screening in cities receiving direct flights from a source area is a second but less desirable option Entry screening in cities not receiving direct flights from a source area are highly inefficient and can be disruptive.

38 SOME IMPORTANT ATTRIBUTES OF SCREENING TOOLS Sensitivity Specificity Cost effectiveness

39 What is the single most important measure to prevent transmission of infectious disease?? 39

40 Thank you for your kind attention!

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